CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior authorization criteria for osteoporosis and related indications (denosumab/other injectable osteoporosis agents)

A prior authorization request form and decision tree used by CVS Caremark (for HMSA patients) to determine coverage of specified osteoporosis medications (e.g., Prolia, Xgeva-like/denosumab brands and other listed products) across indications including postmenopausal osteoporosis, male osteoporosis, glucocorticoid-induced osteoporosis, breast cancer- or prostate cancer-related bone loss. It captures required clinical information (diagnosis, DEXA T-score, FRAX, prior therapy, fragility fractures) and documents when approval may be granted.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization criteria for osteoporosis and related indications (denosumab/other injectable osteoporosis agents)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must complete and fax the prior authorization form with required supporting documentation (diagnosis, DEXA T-score, FRAX scores, documentation of prior bisphosphonate/injectable therapy failure or contraindication, glucocorticoid dose/duration, fracture documentation) to CVS Caremark at 1-866-237-5512.

POLICY UPDATE CHANGES

No material changes to clinical coverage criteria.

5Primary indication branches (postmenopausal, male, glucocorticoid-induced, breast, prostate)

3Key numeric thresholds (DEXA, FRAX, glucocorticoid dose)

2Required prior therapy conditions (bisphosphonate, injectable)

Coverage Summary

This document is a prior authorization request form and decision tree used by CVS Caremark (for HMSA patients) to determine coverage for specified osteoporosis medications across multiple indications including postmenopausal osteoporosis, male osteoporosis, glucocorticoid-induced osteoporosis, and cancer-related bone loss. It operationalizes authorization by capturing required clinical information (diagnosis, DEXA T-score, FRAX scores, prior therapy history, fragility fracture documentation) and specifies when approval may be granted. The coverage stance is mixed and the policy status is CURRENT.

Key clinical thresholds

DEXA T-score (osteoporotic)<= -2.5

DEXA T-score (osteopenia range)< -1 to > -2.5

FRAX 10-year major osteoporotic fracture risk threshold> 20%

FRAX 10-year hip fracture risk threshold> 3%

Glucocorticoid exposure for GIOP pathway>= 2.5 mg/day prednisone equivalent for >= 3 months

Required bisphosphonate trial duration for failure/intolerance>= 1 year (oral or injectable)

Maximum duration - Evenity (romosozumab)12 months

Maximum duration - Forteo (teriparatide)24 months

Provider Actions & Submission Requirements

Prior Authorization

Submit prior authorization request to CVS Caremark

Providers must complete and fax the prior authorization form with required supporting documentation (diagnosis, DEXA T-score, FRAX scores, documentation of prior bisphosphonate/injectable therapy failure or contraindication, glucocorticoid dose/duration, fracture documentation) to CVS Caremark at 1-866-237-5512.

Fax: 1-866-237-5512

Documentation Required

Submit objective test results

Attach pretreatment DEXA T-score and documented FRAX calculations and records supporting prior therapy failure/intolerance or clinical reasons to avoid bisphosphonates.

DEXA T-score (pretreatment)
FRAX calculations (major and hip)
Documentation of prior bisphosphonate/injectable therapy failure or intolerance
Documentation of clinical reason to avoid bisphosphonates

Documentation Required

Glucocorticoid documentation

For glucocorticoid-induced osteoporosis, document glucocorticoid dose and duration (>=2.5 mg prednisone equivalent for >=3 months) to support approval.

Glucocorticoid dose >= 2.5 mg/day prednisone equivalent
Duration >= 3 months

Billing Rule

Contact points for questions/eligibility

For authorization questions contact CVS Caremark; for eligibility, drug copay, or medication delivery contact CaremarkConnect or the Specialty Customer Care Team.

CVS Caremark phone: 1-808-254-4414
CaremarkConnect / Specialty Customer Care Team for eligibility/drug copay/medication delivery

Background & Definitions

The form operationalizes prior authorization determinations for osteoporosis therapies administered or dispensed in various settings and asks the provider to fax completed requests and supporting documentation to CVS Caremark. It requests the diagnosis, DEXA T-score, FRAX scores, documentation of prior bisphosphonate or injectable therapy failure or intolerance, clinical reasons to avoid bisphosphonates, fragility fracture evidence, and—where relevant—glucocorticoid dose and duration. Approvals may be subject to dosing limits per FDA-approved labeling, accepted compendia, and evidence-based practice guidelines.

Definitions

Policy scope and thresholds summary

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization criteria for osteoporosis and related indications (denosumab/other injectable osteoporosis agents)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

On This Page

	Prolia (listed as product option on form)
	Jubbonti (listed)
	Stoboclo (listed)
	Conexxence (listed)
	Ospomyv (listed)

OpenPayer

Prior authorization criteria for osteoporosis and related indications (denosumab/other injectable osteoporosis agents)

Coverage Summary

Medical-Necessity Criteria and Decision Trees

Coding

Provider Actions & Submission Requirements

Background & Definitions

Revision History